Frequently Asked Questions

Q: How do I know if a code requires prior authorization?
A: From the Coverage and Reimbursement Lookup Tool , choose the correct provider type, enter the code that is being requested, and the date that the service will be provided. If the code has age or quantity limitations or requires prior authorization, it will be listed under each column for Traditional, Non-Traditional and PCN.

Or

Send an e-mail to: medicaidcriteria@utah.gov.
Please make sure to include the CPT/HCPCS codes for the criteria that you are requesting, the provider type, and also the type of coverage (Traditional, Non-Traditional or PCN) and allow 24-hours to receive the requested criteria. Please do not send any protected health information (PHI) through unsecured email and allow a 24-hour response time for criteria requests.

Q: What do I need to send in with my request?
A: A current copy of the Prior Authorization Request Form that has all mandatory fields completed correctly and legibly. (Mandatory fields can be found on page 3 of the Prior Authorization Request Form). In addition to the completed form, please submit all supporting documentation that is required in the criteria for the service that is being requested.

Q: Where can I find the criteria for the service that I am requesting?
A: Criteria for Medical/Surgical Procedures, Imaging, and Durable Medical Equipment can be found on the Utah Medicaid Criteria page , as well as some Dental and Therapies and Education criteria. Criteria that are not found in the drop down menus can be found in the appropriate provider manual for the service that is being requested, as well as in code specific “special notes” on the Coverage and Reimbursement Lookup Tool.

For a copy of criteria that is not found on the website, please call the Prior Authorization Staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program.

You may also send an email, including the CPT/HCPCS codes, the provider type, and the type of coverage (Traditional, Non-Traditional or PCN) to: medicaidcriteria@utah.gov. Please do not send any PHI through unsecured email and allow a 24-hour response time for criteria requests.

Q: How do I know if my request was received?
A: If you have received a fax confirmation at the time the request was submitted, please retain that confirmation for your records. If you would like to inquire if the request has been received or what the status of the request is, please call the prior authorization staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program. Be prepared with your Provider NPI/API number (if applicable), the name and Medicaid ID of the member and the date, time and fax number that the request was sent from.

Q: Can you pull this request (out of order) and process it?
A: We do have the ability to process urgent requests, out of order. If the request that was submitted is urgent, and should not be processed in the order that it was received, please call the prior authorization staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program. Information regarding the urgent nature of the need must be identified. Please note that conditions that are considered medically emergent (ie. D&C’s for fetal demise) are not expected to receive authorization prior to the procedure being performed but should be submitted as soon as possible and will not be reimbursed until authorization is approved. If you have questions regarding this policy, please contact the prior authorization staff and be prepared with your Provider NPI/API number (if applicable), the name and Medicaid ID of the member and the date, time and fax number that the request was sent from.

Q: Where do I get a Prior Authorization Request Form?
A: The required forms can be found on the Utah Medicaid website, under Health Care Providers, Prior Authorization, Forms . Only current copies of Utah Medicaid forms will be accepted, all other forms will be returned without being processed.

Q: How do I get a password to see the Criteria?
A: Follow the instructions found on the Utah Medicaid website, under Health Care Providers, Prior Authorization, Criteria.

Q: My claim was denied because it required prior authorization, what do I do now?
A: If a claim was denied for needing a prior authorization, submit a request for prior authorization and all supporting documentation. Be sure to identify that the request is a retroactive request and provide an explanation in the Summary of History section on the Prior Authorization Request Form.

Q: Are services ever authorized retroactively?
A: Yes. Services can be authorized after they have been provided if the service was provided in a medically emergent situation or if Medicaid eligibility is approved after the date that the service is provided and the eligibility is post-dated back to the date of service, the request will be reviewed as if it were submitted prior to the service being provided and is still reviewed using the appropriate criteria.

Q: Is our patient eligible for Medicaid?
A: Eligibility can be verified by calling the Access Now Line at (801) 538-6155 or by using the Eligibility Lookup Tool .

Q: I already received a prior authorization but the code that I asked for is not the code that I needed?
A: Submit a prior authorization request and be sure to indicate in field #4 on the form that this is a change to a current prior authorization and include the previous prior authorization number. Please include an explanation of why the change in codes is needed, in the Summary of History section of the form.